Healthcare Provider Details

I. General information

NPI: 1528424470
Provider Name (Legal Business Name): SHIRLEY THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 W CENTER ST STE 12A&12B
MANTECA CA
95337-7300
US

IV. Provider business mailing address

955 W CENTER ST STE 12A&12B
MANTECA CA
95337-7300
US

V. Phone/Fax

Practice location:
  • Phone: 209-239-9600
  • Fax: 209-239-2244
Mailing address:
  • Phone: 209-239-9600
  • Fax: 209-239-2244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: